research article emergency sonography aids diagnostic...

Research ArticleEmergency Sonography Aids Diagnostic Accuracy ofTorso Injuries: A Study in a Resource Limited Setting

Charles Edward Tunuka,1 Robert Wangoda,1 Sam Bugeza,2 and Moses Galukande1

1 Department of Surgery, Makerere University College of Health Sciences, Kampala, Uganda2Department of Radiology, Makerere University College of Health Sciences, Kampala, Uganda

Correspondence should be addressed to Charles Edward Tunuka; [email protected]

Received 24 March 2014; Revised 27 May 2014; Accepted 23 June 2014; Published 8 July 2014

Academic Editor: Chak W. Kam

Copyright © 2014 Charles Edward Tunuka et al.This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in anymedium, provided the originalwork is properly cited.

Introduction. Clinical evaluation of patients with torso trauma is often a diagnostic challenge. Extended focused assessment withsonography for trauma (EFAST) is an emergency ultrasound scan that adds to the evaluation of intrathoracic abdominal andpericardial cavities done in FAST (focused assessment with sonography for trauma). Objective. This study compares EFAST (theindex test) with the routine standard of care (SoC) investigations (the standard reference test) for torso trauma injuries.Methods.A cross-sectional descriptive study was conducted over a 3-month period. Eligible patients underwent EFAST scanning and theSoC assessment.The diagnostic accuracy of EFAST was calculated using sensitivity and specificity scores. Results. We recruited 197patients; the M : F ratio was 5 : 1, with mean age of 27 years (SD 11). The sensitivity of EFAST was 100%, the specificity was 97%, thePPV was 87%, and the NPV was 100%. It took 5 minutes on average to complete an EFAST scan. 168 (85%) patients were EFAST-scanned. Most patients (82) (48%) were discharged on the same day of hospitalization, while 7 (4%) were still at the hospital aftertwo weeks.Themortality rate was 18 (9%).Conclusion. EFAST is a reliable method of diagnosing torso injuries in a resource limitedcontext.

1. Introduction

Evaluation of patients with torso trauma is often a diagnosticchallenge for emergency physicians and trauma surgeons.Uncontrolled hemorrhage is responsible for over 50% oftrauma related deaths [1–3]. Significant bleeding into theperitoneal, pleural, or pericardial spaces may occur with-out obvious signs [4, 5]. Physical findings may be unreli-able because of decreased patient consciousness, neurologicdeficit, medication, or other associated injuries like fracturesof lower chest ribs, contusion, and abrasions of the abdominalwall. All these call for a need to confirm internal injury byimaging as uncontrolled haemorrhage because torso traumais one of the major causes of early trauma deaths [6].

However, in many rich trauma centers, bedside ultra-sound is the initial imagingmodality used to evaluate patientswith blunt and penetrating torso trauma. This cannot besaid for many countries in sub-Saharan Africa. Yet bedsideultrasound is cheap, noninvasive, and fast leading to early

intervention and hence potential reduction in mortality[5, 7].

The purpose of this study therefore was to determinethe diagnostic accuracy of EFAST when compared with theroutine standard of care (SoC) assessment for torso traumainjuries in a resource limited setting.

2. Methods

2.1. Design. Across-sectional analytical studywas conducted.

2.1.1. Study Setting. The study was carried out at the A&Eunit of Mulago National Referral and Teaching Hospitalin Kampala city. The unit is fully fledged with medicaland surgical wings, two operating rooms, with X-ray andultrasound facilities, a high dependence unit (with threebeds), and a thirty-bed holding emergency ward. Adjacentto it are blood bank, hematology, microbiology, and clinicalchemistry laboratories. The unit sees on average 30 patientswith internal torso per month.

Hindawi Publishing CorporationEmergency Medicine InternationalVolume 2014, Article ID 978795, 6 pageshttp://dx.doi.org/10.1155/2014/978795

2 Emergency Medicine International

2.1.2. Study Population. All patients who were clinicallysuspected to have torso injury presented to the A&E unit inMulago Hospital during the study period and consented tothe study.

These included patients with torso abrasions and/orbruises, unconsciousness, multiple injuries, alcohol intoxica-tion with trauma, long bone fractures, pelvic fractures, andspine injuries.

Those with penetrating injuries and burns with no othertrauma injuries were excluded.

2.2. Sampling. Patients were recruited consecutively onarrival at the A&E unit; they were triaged and transferredto the appropriate examination rooms for further assessmentaccording to the ATLS protocol. Patients in need of operativemanagement were immediately taken to the operating roomwhile those assigned to the nonoperative management planwere admitted to the 24 h holding emergency ward forobservation.

Patients consented after they were resuscitated; a specialrequest was obtained from the IRB for a waiver of consentfor the unconscious and those without relatives. History andexamination findings were recorded on precoded question-naires. Patients suspected to have torso injuries underwentEFAST using SonoSite TITAN portable ultrasound machinewith a transducer frequency ranging from 3.5 to 5MHz.Images were saved to be reread by a consultant radiologistas a quality control measure. Patients then underwent sec-ondary survey followed by other routine investigations andmanagement according to the hospital’s SoC; this consistedof a CXR and abdominal ultrasound scanning preceded by aphysical examination and history taking.The CXR was takenby a radiographer and read by an experienced radiologist.The abdominal ultrasound scans were taken by experiencedoperators.The history taking and physical examinations wereperformed by an intern doctor and validated by residents anda consultant surgeon in succession.

2.3. EFAST Procedure

2.3.1. Examination of the Right Upper Quadrant. The trans-ducer was placed in the midaxillary line between the 11th and12th ribs, applying coronal scan with the probe (cranially orcaudally andmedially or laterally) to obtain an optimal imageof Morison’s pouch and looking for free fluid in it. Findingswere recorded on coded questionnaires.

2.3.2. Assessing for Fluid in Right Pleural Cavity. The probewas moved slightly upwards from position of Morison’spouch to look for fluid in the right pleural cavity. Findingswere recorded on a coded questionnaire.

2.3.3. Examination of the Left Upper Quadrant. The probewas placed along the left posterior axillary line between the8th and 11th ribs. If rib shadows were seen then the probewas placed between the ribs (along the intercostal space)to avoid poor acoustic window. Findings were recorded oncoded questionnaires.

2.3.4. Assessing for Fluid in Left Pleural Cavity. The probefrom splenorenal view was angled with beam direction morecephalad for well visualisation of the spleen and diaphragmand the fluid above the diaphragm was observed. Findingswere recorded on coded questionnaires.

2.3.5. Assessing for Free Fluid in Pelvis. The probe wasplaced in transverse position 2 cm above pubis (for transverseimaging of the bladder) and then turned longitudinally (forlongitudinal imaging of the bladder). Findings were recordedon coded questionnaires.

2.3.6. Assessing for Pneumothorax. Theprobe was placed per-pendicular to the ribs in the anterior chest region intercostalspaces 2-3 along the midclavicular line. This was usuallydone at 3rd-4th intercostal spaces. When visualization wasinadequate, the probe was rotated on 90 degrees, placing itdirectly in the intercostal space along the ribs. Absence of“lung sliding” was a sign of pneumothorax. Findings wererecorded on coded questionnaires.

2.3.7. Assessing for Fluid in Pericardium. Subxiphoid pericar-dial window which has been considered the gold standardfor the diagnosis of pericardial effusion was used. In thepositive examination there was anechoic space (collection offluid) between the heart and the pericardium. Findings wererecorded on a coded questionnaire.

2.4. Study Variables. These included age, sex, tribe, andoccupation.

In addition, signs indicating torso trauma were abra-sions and bruises.Unconsciousness,multiple injuries, alcoholintoxication, long bone fractures, pelvic fractures, and spineinjuries were the other variables.

Hemoperitoneum, hemopericardium, hemothorax, andpneumothorax were also included.

2.5. Data Collection, Management, and Analysis. Data col-lected using pretested questionnaires were double entered,coded, and cleaned using EpiData version 5.3.2 softwarepackage.

Stored data were exported to STATA version 12 for anal-ysis. Categorical and numerical variables were summarizedusing portions, frequency tables, pie charts, and bar charts.Continuous data were summarized intomeans, medians, andstandard deviations. Usefulness of EFAST was determinedby calculating sensitivity and specificity of EFAST diagnosesafter comparison with the SoC diagnoses made.

2.6. Ethical Considerations. Written informed consent wasobtained from the participants and permission was obtainedfrom IRB for the patients unable to consent because of theirunconscious state and having no available next-of-kin.

3. Results

A total of 197 patients were clinically suspected to have torsoinjury. These patients were subjected to EFAST and the SoC.

Emergency Medicine International 3

EFAST Standard of care

5 had pneumothorax 4 had haemothorax

4653 patients suspected to have torso injury

197 patients were included in the study and underwent EFAST scan and

standard of care diagnoses

23 were positive for hemoperitoneum

1 had haemopericardium

4456 patients were excluded

21 hadhemoperitoneum

9 had haemothorax

None had haemopericardium

10 had haemothorax

Figure 1: Study for the emergency ultrasound scan torso trauma Uganda study, 2012.

EFAST scanning took on average 5 minutes to complete foreach patient.The scanning was done during resuscitation justafter the primary survey.The study was done from January toMarch 2012 (see Figure 1).

3.1. The Baseline Characteristics. The male : female ratio was5 : 1. The age ranged from 2 to 83 years with mean age 26.9years (SD of 11). There were 29 (14%) victims whose age wasless than 18 years, 158 (80%) were aged between 19 and 45years, and 10 were >45 years old. 78 (40%) patients arrivedat unit before an hour had elapsed from time of injury. 168(85%) patients were EFAST scanned within an hour fromadmission while most patients (105) (54%) underwent SoCinvestigations after an hour of stay at the hospital. Mostpatients (82) (48%) were discharged on the same day ofhospitalization. By the end of the first week 151 (77%) patientshad been discharged while 13 (7%) patients were dischargedon the second week and 7 (4%) were still at the hospital bythe end of the two weeks. 18 (9%) of the participants had died(see Table 1).

Most patients (72%) had undergone EFAST within 30minutes of admission.

In one hour the emergency room doctor could establisha diagnosis on internal injury in only 17% of patients.

RTC was the main reason for hospitalization.

3.2. Circumstances of Injury. The cause of most of the injurieswas due to motor traffic crashes (127) (65%). Assault was thesecond largest cause of injuries affecting 61 patients (31%),followed by falls affecting 6 individuals (3%), while othercauses contributed to 3 injuries (2%). Of the motor trafficcrashes 53 were the most affected (27%) followed by motorbike victims (41) (21%). Taxis and private cars contributed tothe remaining percentage of the victims. Of the motorbikeinjuries 31 (62%) were the motorbike riders while 19 (38%)were passengers.

3.3. External Injuries. There were 23 (12%) participants whodid not present with any external injuries. In most instances,participants had more than one presentation of externalinjuries. All presentations were recognized at the time ofadmission and the sites of external injuries (see Table 2).

Most of the patients (168) (85%)were bruised and onewasburnt (0.50%).

The chest was the most affected region in 130 (66%)followed by the head.

3.4. EFAST Findings. Of 197 patients who underwent EFAST,23 (12%) were positive for hemoperitoneum, 10 (5%) werepositive for hemothorax, 5 (2.5%) were positive for pneu-mothorax, and one (0.5%)was positive for hemopericardium.

3.5. SoC Findings. Among patients who underwent standardof care investigations there were 21 (11%) patients withhemoperitoneum, 9 (5%) were positive for hemothorax, 4(2%) were positive for pneumothorax, and none was positivefor hemopericardium.

3.6. Validity Testing. Validity testing was done as shown inTable 3.

3.7. Management Strategies. Overall 14 (7%) patients weremanaged operatively while 83 (93%) were managed nonop-eratively. There were 4 (2%) patients with hemoperitoneumand 8 (4%) with hemothorax. One patient had a grade foursplenic injury and one other a liver laceration in combinationwith gut perforation. One patient who failed nonoperativemanagement with a hemoperitoneum died en route to theoperating roomand the eight patientswith hemothoraces hadtube thoracostomies done.


Table 1: Distribution of characteristics between EFAST and stan-dard of care.

Characteristic Number𝑁 = 197

Percentage

Age<18 29 1419–45 158 80>45 10 5

GenderMale 165 84Female 32 16

Duration from time of injury toadmission<1 hour 79 40>1 hour 118 60

Duration of admission to EFAST<1 hour 168 85>1 hour 29 15

Duration of admission to standard of care<1 hour 92 47>1 hour 105 53

Status of patient at study endDead 18 9

Waiting time for EFAST1–30mins 142 7231–60mins 17 9>60mins 38 19

Duration lapsed before standard of careinvestigation was performed

0–30mins 8 431–60mins 25 13>60mins 164 83

Causes of trauma among the patientsrecruited

Road traffic crash 127 64.5Assault 61 31Fall 6 3Others 3 2

4. Discussion

We set out to determine the utility of emergency ultrasoundscanning for the torso trauma patients in a resource limitedcontext.We found that EFAST had high sensitivity and speci-ficity in a low-resourced, high patient turnover environment.There were more males than females injured, similar to aprevious study at the unit [8]. The mean age was 27 yearsattesting to the fact that the youths are the most vulnerable[8, 9].

A fair number of patients (78) (40%) arrived at theA&E within the first hour of injury. This applies more topatients whose district of origin was within 25 km of radius

Table 2: Distribution of external injuries.

External injuries Number𝑁 = 197

Percentage

Bruises 168 85No bruises 29 15Abrasions 135 69No bruises 62 31Lacerations 67 30No lacerations 130 66Cuts 30 15No cuts 167 85Burns 1 1No burns 196 99Injury

Presence of abdominal injuries 40 20Absence of abdominal injuries 157 80Presence of head injuries 102 52Absence of head injuries 95 48Presence of chest injuries 130 66Absence of chest injuries 67 34Presence of back injuries 47 24Absence of back injuries 150 76Presence of lower limb injuries 93 47Absence of lower limb injuries 104 53

of the hospital. Most of the patients who came from moreperipheral districts arrived at the hospital by the second day.

Most of the patients underwent EFASTwithin 30minutesof admission; 159 (81%) had undergone EFAST within onehour. Most of the SoC diagnoses did not differ from thosereached by bedside ultrasound (EFAST). Several studiessupport bedside ultrasound as it is fast, affordable, andnoninvasive [10–12]. The concept of the golden hour intrauma stresses the fact that most trauma patients can besaved if attended immediately after injury.This can be helpedif an ultrasoundmachine is stationed within the resuscitationroom and performed immediately when internal injury issuspected during initial assessment [5, 7]. EFAST improvescare by providing a quicker method of assessment, lessreliance of radiology staff (who we have few of), and by itsready availability within the resuscitation room.

4.1. EFAST and Standard of Care

4.1.1. Hemoperitoneum. In patients who underwent bothEFAST and SoC which included full abdominal ultrasoundscanning, 23 (12%) were positive at EFAST and 21 werepositive at full abdominal ultrasound scanning. The twopatients who were considered positive at EFAST but negativewhen subjected to SoC investigations were among the non-operatively managed group; therefore EFAST findings couldnot be validated. Two patients who were considered positivewhen subjected to SoC investigations underwent surgery and

Emergency Medicine International 5

Table 3: Validity testing of EFAST taking standard of care as the gold standard.

EFAST Standard of care — — — — —Clinical findings Presence Absence Total Sensitivity (%) Specificity (%) PPV (%) NPV (%)Normal 34 5 39Abnormal 0 143 143 100 97 87 100

a specific diagnosis of solid organ injury was made. In thesetwo patients the radiological diagnosis was ruptured spleen;however, a ruptured liver and urinary bladder were missedin the first patient and a ruptured spleen was missed in thesecond patient. Several studies point out that ultrasound isvery sensitive in fluid detection but poorly sensitive in solidorgan injuries detection [5].

In one patient both EFAST and abdominal ultrasoundscan diagnoses were normal but on the second day thepatient was still complaining of severe abdominal pain andthe abdomen was distended. An exploratory laparotomy wasdone and the patient had a rupture small gut. Ultrasoundis shown by several studies to be sensitive for detectionof abdominal fluid accumulation, which is assumed to beblood in acute trauma but has little role in diagnosis of gutperforation in which it can describe fluid level in nonacuteperforation [5, 6].

In two other patients, ruptured small gut was missedby both EFAST and full abdominal ultrasound scans onlyto be diagnosed intraoperatively on failure of conservativemanagement.

4.1.2. Hemothorax. Of the patients who underwent bothEFAST and standard of care, chest X-ray in this case, forthoracic complaints 10 (5%) were positive on EFAST and 9(5%) on chest X-ray. The entire nine patients were managedaccording to the standard of care. The patient who was pos-itive on EFAST alone was managed nonoperatively becausethe hemothorax was small. Ultrasound is more sensitive inthe detection of hemothorax than a chest X-ray [5, 13].

Ultrasound can detect as little as less than 20 milliliterswhile an ordinary chest X-ray can pick a hemothorax of150mLs on maneuvering the position of the patient whentaking the X-ray picture [5].

4.1.3. Pneumothorax. Five (3%) and 4 patients (2%) werepositive for pneumothorax on EFAST and SoC, respectively.(In SoC a chest X-ray was used.) All patients were managedoperatively. Thoracic ultrasound is shown by several studiesto be highly sensitive in detecting hemopneumothorax. Itssensitivity has been demonstrated to be up to 100% andspecificity of 99.7% [5].This is reflected in this study in whichone patient diagnosis was missed in the initial chest X-ray(standard of care).

4.1.4. Hemopericardium. There was one patient who had ahemopericardium detected as a small collection on ultra-sound but wasmissed on chest X-ray.Thismay not have beenblood but could be an effusion. The patient was managedconservatively. As it is shown bymany other previous studies,ultrasound is very sensitive in fluid detection [10].

4.1.5. EFAST Performance. Performance of EFAST wasassessed by calculating diagnostic sensitivity, specificity, andpositive and negative predictive values.

EFAST sensitivity and specificity were 100% and 97%,respectively. Positive and negative predictive values were 87%and 100%, respectively. The findings are similar to severalother studies [5, 14–16].

4.1.6. Patients’ Deposition at Two Weeks. Patients were fol-lowed up for two weeks. For patients who had been dis-charged a phone call was made at the end of the second weekto get general information on how they are and if they gotback to any hospital for a reason of worsening of the dischargediagnosis and in that way it was possible to establish if theywere alive. Mortality rate was 9% and this was relatively high;in study by Gyayi in Uganda the mortality was 7% and othersimilar studies state 4% to 5% [17–20].

4.2. Study Limitations. No postmortems were done for thefatalities and for the patients managed nonoperatively; therecould not be intraoperative findings to validate EFASTfindings.

The low frequency transducer that was used could havemissed some positive findings.

Emergency US scanning performed may be operatordependent, though some studies show that FAST can bereliably done by a radiologist and nonradiologist [21].

5. Conclusion

EFAST, an emergency ultrasound scanning technique, ishighly sensitive and specific assessment modality for torsoinjury. It should be adopted for routine use in low resourcecontexts.

Conflict of Interests

The authors declare that there is no competing interests.

Authors’ Contribution

Charles Edward Tunuka originated the concept. MosesGalukandewrote the first draft.All authors performed criticalreviews for intellectual content and agreed to the final paper.

Acknowledgments

The authors would like to acknowledge the Staff in Acci-dent and Emergency unit, Mulago Hospital, Department ofSurgery, and colleagues and all the study participants.


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